Hematuria¶
Laura Binari/Patrick Steadman
Background¶
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Definition: 3 urinalyses with three or more RBC/hpf; 1 urinalysis with 100 RBC/hpf or gross hematuria (1 cc blood/L urine can induce color change)
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Causes:
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Can be transient (exercise-induced, menses, trauma)
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Concurrent pyuria/dysuria: consider urinary tract infection or bladder malignancy
- Malignancy risk factors: male sex, age > 50, smoking Hx, exposures to benzene/aromatic amine, cyclophosphamide, indwelling foreign body, pelvis irradiation, chronic UTIs, heavy NSAID use, urologic disorders (nephrolithiasis, BPH)
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Recent URI: think infection related glomerulonephritis, IgA, vasculitis, anti-GBM
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Positive Family Hx of Hematuria: consider PKD, Sickle Cell Disease
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Bleeding from other sites: think inherited/acquired bleeding disorder, anticoagulation
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Unilateral Flank Pain: Ureteral calculus, renal malignancy, IgA Nephropathy
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| Glomerular | Extraglomerular (Non-Glomerular Source) | |||
|---|---|---|---|---|
| Kidney | Ureter/ Bladder |
Prostate/ Urethra |
Other | |
IgA Nephropathy IgA Vasculitis |
Pyelo | Cystitis | BPH | Exercise-Induced |
| Lupus Nephritis | Renal Cell Carcinoma | Urothelial Malignancy | Prostate Cancer | Bleeding Diathesis |
| Infection-related glomerulonephritis | PKD | Nephrolithiasis | TURP | Meds (AC) |
| Anti-GBM Disease (Goodpasture’s) | Sickle Cell Papillary Necrosis |
Ureteral Stricture | Urethritis (STI) | Menses |
| ANCA-associated | Malignant HTN | Hemorrhagic Cystitis (chemo/rads) | TB Schistoso-miasis |
|
| Genetic (Thin Basement Membrane Nephropathy/Alport Syndrome) | Arterial embolism Vein thrombus |
Traumatic Foley/procedure | ||
Evaluation
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Step 1: Confirm the presence of hematuria
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Dipstick positive heme: urinary RBCs (hematuria), free myoglobin or free hemoglobin
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Centrifuge the urine
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Red sediment -> true hematuria (urinary RBCs)
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Red supernatant +
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Positive dipstick: myoglobulin or hemoglobin
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Negative dipstick porphyria, Pyridium, beets, rhubarb, or ingestion of food dyes
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| Glomerular | Extraglomerular | |
|---|---|---|
| Color (if gross hematuria) | Red, Cola, Smoky | Red/Pink |
| Clots | Absent | Present/Absent |
| Proteinuria | May be >500 mg/day | \<500 mg/day |
| RBC morphology | Dysmorphic RBCs present | Normal (isomorphic) |
| RBC casts | May be present | Absent |
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Step 2: Determine if there is a GLOMERULAR or NON-GLOMERULAR source of bleeding
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Glomerular Bleeding:
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Isolated Hematuria: Differential includes IgA Nephropathy, thin BM dx, Alport’s
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Nephritic syndrome (new proteinuria, pyuria, HTN, edema, rise in Cr): post-infectious GN, MPGN, ANCA vasculitis, Goodpasture’s, lupus nephritis
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Workup: anti-GMB, anti-DNase/ASO, ANA, ANCA, C3, C4, cryo, Hep B & C, HIV
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Indications for Renal Biopsy: glomerular bleeding + risk factors for progressive disease, including albuminuria > 30 mg/day, new hypertension > 140/90 or significant elevation over baseline BP, rise in serum creatinine
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Extraglomerular Bleeding (Imaging Section)
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If historical clues suggest nephrolithiasis, start with non-con CT A/P
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Gross Hematuria otherwise should be evaluated with CT A/P w/ and w/o contrast (CT urography); consult urology for cystoscopy (often done as outpatient referral)
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If clots are passed, more likely to be secondary to lower urinary source, and if a high burden of clots poses a risk of obstruction (urologic emergency)
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If extraglomerular bleeding with clots: hematuria catheter needs to be placed ASAP (2 valve catheter, 20-24 Fr (!); page urology if nursing unable to obtain)
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CT Urography is more sensitive than IV pyelogram for renal masses and stones.
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Prefer Renal and Bladder Ultrasound in pregnant patients
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All pts w/gross hematuria that is non-glomerular in source, in whom infection has been ruled out, warrant cystoscopy. Additionally, all patients with clots need cystoscopy